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Davidson’s
Self-assessment in
Medicine
This page intentionally left blank
Davidson’s
Self-assessment in
Edited by

Deborah Wake
MB ChB (Hons), BSc, PhD, Diploma Clin Ed, MRCPE
Clinical Reader, University of Edinburgh; Honorary Consultant
Physician, NHS Lothian, Edinburgh, UK

Patricia Cantley
MB ChB, FRCP, BSc Hons (Med Sci)
Medicine
Consultant Physician, Midlothian Enhanced Rapid Response and
Intervention Team, Midlothian Health and Social Care Partnership
and also Royal Infirmary of Edinburgh and Midlothian Community
Hospital, Edinburgh, UK

Edinburgh London New York Oxford Philadelphia

St Louis Sydney 2018
© 2018, Elsevier Limited All rights reserved.

No part of this publication may be reproduced or transmitted in any form or

by any means, electronic or mechanical, including photocopying, recording,
or any information storage and retrieval system, without permission in writing
from the publisher. Details on how to seek permission, further information
about the Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/
permissions.
This book and the individual contributions contained in it are protected
under copyright by the Publisher (other than as may be noted herein).

Notices
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds or
experiments described herein. Because of rapid advances in the medical
sciences, in particular, independent verification of diagnoses and drug
dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or
damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.

ISBN: 978-0-7020-7151-5
International ISBN: 978-0-7020-7145-4

Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Executive Content Strategist: Laurence Hunter

Content Development Specialist: Carole McMurray
Project Manager: Louisa Talbott
Design: Miles Hitchen
Illustration Manager: Nichole Beard
Illustrator: MPS North America LLC
Marketing Manager: Deborah Watkins
 Contents
Preface vii
Introduction ix
Contributors xi
Abbreviations xv

1. Clinical decision-making 1
2. Clinical therapeutics and good prescribing 6
3. Clinical genetics 14
4. Clinical immunology 22
5. Population health and epidemiology 28
6. Principles of infectious disease 32
7. Poisoning 37
8. Envenomation 46
9. Environmental medicine 51
10. Acute medicine and critical illness 54
11. Infectious disease 73
12. HIV infection and AIDS 96
13. Sexually transmitted infections 103
14. Clinical biochemistry and metabolic medicine 107
15. Nephrology and urology 115
16. Cardiology 132
17. Respiratory medicine 154
18. Endocrinology 185
19. Nutritional factors in disease 203
20. Diabetes mellitus 212
21. Gastroenterology 225
vi • Contents

22. Hepatology 245

23. Haematology and transfusion medicine 261
24. Rheumatology and bone disease 278
25. Neurology 299
26. Stroke medicine 325
27. Medical ophthalmology 330
28. Medical psychiatry 336
29. Dermatology 345
30. Maternal medicine 366
31. Adolescent and transition medicine 370
32. Ageing and disease 377
33. Oncology 383
34. Pain and palliative care 393
35. Laboratory reference ranges 402

Colour illustrations 415

Index 423
 Preface
This is the first edition of Davidson’s Self-assessment in Medicine, designed as an accompanying
volume to the internationally renowned textbook Davidson’s Principles and Practice of Medicine.
Since the original Davidson’s was first published in 1952, it has acquired a large following of medical
students, doctors and health professionals. Alongside the success of the main textbook, a demand
has emerged for a complementary self-assessment book covering a broad range of general medicine
topics. Our new book uses typical clinical scenarios to test the reader. Each chapter is written by a
specialty expert and the contents follow the style and chapter layout of Davidson’s. This book can
be used either independently or in conjunction with the main book.
This book has been built around modern educational principles and utilises a contemporary assess-
ment style, in line with current undergraduate and postgraduate teaching. It is designed to help and
support students in their final undergraduate years and in the early years after qualification. The style
is compatible with that used in modern postgraduate examinations across the world.
The clinical scenarios have been chosen to be suitable for clinicians at any stage in their career,
supporting ongoing professional development. Clinical reasoning and judgement are encouraged,
with questions mirroring the situations and presentations that clinicians will meet in their everyday
practice. The content is applicable to a global audience and is based on current evidence-based best
practice.
The modern physician needs not only a sound knowledge base but also the ability to apply that
understanding appropriately to individual patients. The vision of the editors is to create a resource
that stimulates readers to build and apply their clinical knowledge to real-life scenarios, resulting in
excellent patient-centred care.
Deborah Wake and Patricia Cantley
Edinburgh, 2018
This page intentionally left blank
 Introduction
This book offers a broad education through formative self-assessment in general internal medicine.
The majority of the questions have been designed around clinical scenarios, with a number of optional
answers offered to the question posed. In general, the ‘best fit’ answer is sought unless otherwise
stated. Full explanations are given as appropriate to assist the reader in their learning.
The questions aim to cover a wide range of topics, divided into specialist chapters in line with
Davidson’s Principles and Practice of Medicine. The questions have in general been based on UK
clinical practice and pharmacology, but where appropriate generic drug names are used and the
underlying principles are applicable internationally. Whilst the answers given are in line with best evidence-
based clinical practice, patient choice and cultural factors should always be considered when applying
the learning in individual patients and situations.

How to use this book

This self-assessment book can be used either independently or in conjunction with Davidson’s.
Readers may find it useful to read the relevant section of the main textbook in advance of tackling
the self-assessment; or they can use it subsequently to explore the topic in greater detail.
The questions, followed by their corresponding answers, have been arranged in the same chapter
order as Davidson’s. The chapters are free-standing and can be read independently in any order.
Some of the questions are based on accompanying clinical images and radiology. Where it is
appropriate to see the image in colour, it has also been reproduced in a colour photographic section
at the back of the book.
Normal Reference Ranges for tests have not been used within the questions or explanations, but
can be found in the laboratory reference range chapter, at the end of the book.
Standard abbreviations are found within the text and are generally explained at first use. A full list
of abbreviations can be found at the front of the book.
This page intentionally left blank

Anna Anderson MBChB, MRCP, PhD
Specialist Registrar Diabetes and Endocrinology,
Western General Hospital, Edinburgh, UK
Brian J Angus BSc (Hons), DTM&H, FRCP,
MD, FFTM(Glas)
Associate Professor, Nuffield Department of
Medicine, University of Oxford, UK
Quentin M Anstee BSc (Hons), MBBS, PhD,
MRCP, FRCP
Professor of Experimental Hepatology, Institute
of Cellular Medicine, Newcastle University,
Newcastle upon Tyne, UK; Honorary Consultant
Hepatologist, Freeman Hospital, Newcastle upon
Tyne NHS Hospitals Foundation Trust, Newcastle
upon Tyne, UK
Jennifer Bain MBChB, MRCP, FRCA, FFICM
Fellow in Vascular Anaesthesia, Scottish
Thoraco-abdominal & Aortic Aneurysm Service,
Royal Infirmary of Edinburgh, Edinburgh, UK
Leslie Burnett MBBS, PhD, FRCPA
Chief Medical Officer, Genome.One,
Garvan Institute of Medical Research,
Darlinghurst, Sydney; Honorary Professor,
University of Sydney, Sydney Medical School,
Sydney; Conjoint Professor, UNSW, St
Vincent’s Medical School, Darlinghurst,
Sydney, Australia
Mark Byers OBE, FRCGP, FFSEM, FIMC,
MRCEM
Consultant in Pre-Hospital Emergency Medicine,
Institute of Pre-Hospital Care, London, UK
Contributors
Harry Campbell MD, FRCPE, FFPH, FRSE
Professor of Genetic Epidemiology and Public
Health, Centre for Global Health Research, Usher
Institute of Population Health Sciences
and Informatics, University of Edinburgh,
Edinburgh, UK
C Fiona Clegg BSc (MedSci), MBChB,
MRCP (UK)
Clinical Lecturer in Gastroenterology, School of
Medicine, Medical Sciences and Nutrition,
University of Aberdeen, Aberdeen, UK
Gavin Clunie BSc, MBBS, MD, FRCP
Consultant Rheumatologist and Metabolic Bone
Physician, Cambridge University Hospitals NHS
Foundation Trust, Addenbrooke’s Hospital,
Cambridge, UK
Lesley A Colvin MBChB, BSc, FRCA, PhD,
FRCP (Edin), FFPMRCA
Consultant/Honorary Professor in Anaesthesia
and Pain Medicine, Department of Anaesthesia,
Critical Care and Pain Medicine, University
of Edinburgh, Western General Hospital,
Edinburgh, UK
Bryan Conway MB, MRCP, PhD
Senior Lecturer, Centre for Cardiovascular
Science, University of Edinburgh; Honorary
Consultant Nephrologist, Royal Infirmary
Edinburgh, Edinburgh, UK
Nicola Cooper MBChB, FAcadMEd, FRCPE,
FRACP
Consultant Physician, Derby Teaching Hospitals
NHS Foundation Trust; Honorary Clinical
Associate Professor, Nottingham University,
Division of Medical Sciences and Graduate Entry
Medicine, Nottingham, UK
xii • Contributors
Dominic J Culligan BSc, MBBS, MD, FRCP,
FRCPath
Consultant Haematologist and Honorary
Senior Lecturer, Aberdeen Royal Infirmary,
Aberdeen, UK
Ruth Darbyshire MB BChir, MA(Cantab)
Specialty Trainee in Ophthalmology, Yorkshire
and Humber Deanery, Yorkshire, UK
Graham Dark MBBS, FRCP, FHEA
Senior Lecturer in Medical Oncology and Cancer
Education, Newcastle University, Newcastle upon
Tyne, UK
Richard J Davenport DM, FRCP (Edin),
BM BS, BMedSci
Consultant Neurologist and Honorary Senior
Lecturer, University of Edinburgh, Edinburgh, UK
David Dockrell MD, FRCPI, FRCP (Glas),
FACP
Professor of Infection Medicine, MRC/University of
Edinburgh Centre for Inflammation Research,
University of Edinburgh, Edinburgh, UK
Emad El-Omar BSc (Hons), MBChB,
MD (Hons), FRCP (Edin), FRSE
Professor of Medicine, St George and Sutherland
Clinical School, University of New South Wales,
Sydney, Australia
Sarah Fadden BA, MB BChir, FRCA
Senior Registrar in Anaesthesia, Royal Infirmary of
Edinburgh, Edinburgh, UK
Catriona M Farrell MBChB, MRCP (UK)
Specialist Registrar Endocrinology and Diabetes,
Ninewells Hospital, Dundee, UK
Amy Frost MA (Cantab), MBBS, MRCP
Clinical Genomics Educator, Affiliated to St
George’s University NHS Foundation Trust,
London, UK
Neil Grubb MD, FRCP
Cardiology Consultant, Royal Infirmary of
Edinburgh; Honorary Senior Lecturer,
Cardiovascular Sciences, University of Edinburgh,
Edinburgh, UK
Jyoti Hansi
Department of Gastroenterology, Royal Infirmary
of Edinburgh, Edinburgh, UK
Sally H Ibbotson BSc (Hons), MBChB (Hons),
MD, FRCP (Edin)
Professor of Photodermatology, Photobiology
Unit, Dermatology Department, University of
Dundee, Dundee, UK
Sara J Jenks Bsc (Hons), MRCP, FRCPath
Consultant in Metabolic Medicine, Department of
Clinical Biochemistry, Royal Infirmary of
Edinburgh, UK
Sarah Louise Johnston MB ChB, FCRP,
FRCPath
Consultant in Immunology & HIV Medicine,
Department of Immunology and Immunogenetics,
North Bristol NHS Trust, Bristol, UK
David E J Jones MA, BM BCh, PhD, FRCP
Professor of Liver Immunology, Institute of Cellular
Medicine, Newcastle University; Consultant
Hepatologist, Freeman Hospital, Newcastle upon
Tyne, UK
Peter Langhorne MBChB, PhD, FRCP (Glas),
Hon FRCPI
Professor of Stroke Care, Institute of
Cardiovascular and Medical Sciences, University
of Glasgow, Glasgow, UK
Stephen Lawrie MD (Hons), FRCPsych,
Hon FRCP (Edin)
Professor of Psychiatry, University of Edinburgh,
Edinburgh, UK
John Paul Leach MD, FRCP
Consultant Neurologist, Institute of Neurological
Sciences, Glasgow; Head of Undergraduate
Medicine, University of Glasgow, Glasgow, UK
Andrew Leitch MBChB, BSc (Hons), PhD,
MSc (Clin Ed), FRCPE (Respiratory)
Consultant Respiratory Physician, Western
General Hospital; Honorary Senior Lecturer,
University of Edinburgh, Edinburgh, UK
Gary Maartens MBChB, FCP(SA), MMed
Professor of Medicine, University of Cape Town,
Cape Town, South Africa
Lucy Mackillop BM BCh, MA (Oxon), FRCP
Consultant Obstetric Physician, Oxford University
Hospitals NHS Foundation Trust; Honorary Senior
Clinical Lecturer, Nuffield Department of
Obstetrics and Gynaecology, University of Oxford,
Oxford, UK

Michael MacMahon MBChB, FRCA, FICM,
EDIC
Consultant in Anaesthesia and Intensive Care,
Victoria Hospital, Kirkcaldy, Fife, UK
Rebecca Mann BMedSci, BMBS, MRCP,
FRCPCh
Consultant Paediatrician, Taunton and Somerset
NHS Foundation Trust, Taunton, UK
Lynn Manson MBChB, MD, FRCP, FRCPath
Consultant Haematologist, Scottish National
Blood Transfusion Service, Department of
Transfusion Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
Amanda Mather MBBS, FRACP, PhD
Consultant Nephrologist, Department of Renal
Medicine, Royal North Shore Hospital; Conjoint
Senior Lecturer, Faculty of Medicine, University of
Sydney, Sydney, Australia
Simon R Maxwell BSc, MBChB, MD, PhD,
FRCP, FRCPE, FHEA
Professor of Student Learning/Clinical
Pharmacology & Prescribing, Clinical
Pharmacology Unit, University of Edinburgh,
Edinburgh, UK
David McAllister MBChB, MD, MPH, MRCP,
MFPH
Wellcome Trust Intermediate Clinical Fellow
and Beit Fellow, Senior Clinical Lecturer in
Epidemiology and Honorary Consultant in
Public Health Medicine, University of Glasgow,
Glasgow, UK
Mairi H McLean BSc (Hons), MBChB (Hons),
PhD, MRCP
Senior Clinical Lecturer in Gastroenterology,
School of Medicine, Medical Sciences and
Nutrition, University of Aberdeen; Honorary
Consultant Gastroenterologist, Digestive Disorders
Department, Aberdeen Royal Infirmary, Aberdeen,
UK
Francesca E M Neuberger MBChB,
MRCP (UK)
Consultant Physician in Acute Medicine and
Obstetric Medicine, Southmead Hospital,
Bristol, UK
Contributors • xiii
David E Newby BA, BSc (Hons), PhD, BM,
DM, DSc, FMedSci, FRSE, FESC, FACC
British Heart Foundation John Wheatley Chair of
Cardiology, British Heart Foundation Centre for
Cardiovascular Science, University of Edinburgh,
Edinburgh, UK
John Olson MD, FRPCE, FRCOphth
Consultant Ophthalmic Physician, Aberdeen
Royal Infirmary; Honorary Reader, University of
Aberdeen, UK
Paul J Phelan MBBCh, MD,
FRCP (Edin)
Consultant Nephrologist and Renal Transplant
Physician, Honorary Senior Lecturer, University of
Edinburgh, Royal Infirmary of Edinburgh,
Edinburgh, UK
Eric M Przybyszewski BS, MD
Resident Physician, Department of Medicine,
Massachusetts General Hospital, Boston, USA
Stuart H Ralston MBChB, MRCP, FMedSci,
FRSE
Professor of Rheumatology, Rheumatic Diseases
Unit, University of Edinburgh, Edinburgh, UK
Jonathan Sandoe MBChB, PhD, FRCPath
Associate Clinical Professor, University of Leeds,
UK
Gordon Scott BSc, FRCP
Consultant in Genitourinary Medicine, Chalmers
Sexual Health Centre, Edinburgh, UK
Alan G Shand MD, FRCP (Ed)
Consultant Gastroenterologist, Gastrointestinal
Unit, Western General Hospital, Edinburgh, UK
Robby Steel MA, MD, FRCPsych
Department of Psychological Medicine, Royal
Infirmary of Edinburgh; Honorary (Clinical) Senior
Lecturer, Department of Psychiatry, University of
Edinburgh, Edinburgh, UK
Grant D Stewart BSc (Hons),
FRCSEd (Urol), MBChB, PhD
University Lecturer in Urological Surgery,
Department of Surgery, University of Cambridge;
Honorary Consultant Urological Surgeon,
Department of Urology, Addenbrooke’s Hospital,
Cambridge; Honorary Senior Clinical Lecturer,
University of Edinburgh, Edinburgh, UK
xiv • Contributors

David R. Sullivan MBBS, FRACP, FRCPA Henry Watson MBChB, MD

Clinical Associate Professor, Clinical Biochemistry,
Royal Prince Alfred Hospital, Camperdown, NSW,
Australia
Victoria Ruth Tallentire BSc (Hons), MD,
FRCP (Edin)
Consultant Physician, Western General Hospital;
Honorary Clinical Senior Lecturer, University of
Edinburgh, Edinburgh, UK
Simon H Thomas MD, FRCP
Professor of Clinical Pharmacoloy and
Therapeutics, Medical Toxicology Centre,
Newcastle University, Newcastle upon Tyne, UK
Consultant Haematologist, Aberdeen Royal
Infirmary, Aberdeen, UK
Julian White MBBS, MD
Professor and Department Head, Toxinology
Department, Women’s & Children’s Hospital,
North Adelaide, Australia
Miles D Witham BM BCh, PhD, FRCP (Ed)
Clinical Reader in Ageing and Health, Department
of Ageing and Health, University of Dundee,
Dundee, UK

Craig Thurtell BMedSci (Hons), MBChB

MRCP
Specialty Registrar, Department of Diabetes &
Endocrinology, Ninewells Hospital, Dundee, UK
 Abbreviations
11β-HSD 11β-Hydroxysteroid APL Acute promyelocytic leukaemia
dehydrogenase APS Antiphospholipid syndrome
131
I Radioisotope iodine-131 APTT Activated partial thromboplastin
2,3-DPG 2,3-Diphosphoglycerate time
20WBCT 20-Minute whole-blood clotting ARDS Acute respiratory distress
test syndrome
5-ASA 5-Aminosalicylic acid ART Antiretroviral therapy
5-HIAA 5-Hydroxyindoleacetic acid AS Ankylosing spondylitis
AAV ANCA-associated vasculitis AST Aspartate aminotransferase
ACE Angiotensin-converting enzyme ATCG Adenine, thymine, cytosine,
AChR Acetylcholine receptor guanine
ACPA Anti-citrullinated peptide antibody ATG Anti-thymocyte globulin
ACR Albumin : creatinine ratio ATN Acute tubular necrosis
ACTH Adrenocorticotrophic hormone AVNRT Atrioventricular nodal re-entrant
ADH Antidiuretic hormone, vasopressin tachycardia
ADP Adenosine diphosphate AVP Arginine vasopressin
ADR Adverse drug reaction AVRT Atrioventricular re-entrant
AED Antiepileptic drug tachycardia
AFLP Acute fatty liver of pregnancy axSpA Axial spondyloarthritis
AFP Alpha-fetoprotein BAL Bronchoalveolar lavage
AICTD Autoimmune connective tissue BCC Basal cell carcinoma
disease BCG Bacille Calmette–Guérin
AIDS Acquired immune deficiency BD Behçet’s disease
syndrome BiPAP Bi-level positive airway pressure
AIH Autoimmune hepatitis BMD Bone mineral density
AK Actinic keratosis BMI Body mass index
AKI Acute kidney injury BNP Brain natriuretic peptide
ALL Acute lymphoblastic leukaemia BP Blood pressure
ALP Alkaline phosphatase BPH Benign prostatic hypertrophy
ALT Alanine transaminase BPPV Benign paroxysmal positional
AMA Antimitochondrial antibody vertigo
AMD Age-related macular degeneration BRCA1 BReast CAncer genes 1
AML Acute myeloid leukaemia BRCA2 BReast CAncer genes 2
ANA Antinuclear antibody Ca2+ Calcium
ANCA Antineutrophil cytoplasmic CA-MRSA Community-acquired meticillin-
antibody resistant Staphylococcus aureus
anti-EMA Anti-endomysial antibody CAH Congenital adrenal hyperplasia
anti-tTG Anti-tissue transglutaminase cAMP Cyclic adenosine monophosphate
APC Argon plasma coagulation CAP Community-acquired pneumonia
APKD Autosomal dominant polycystic CBT Cognitive behavioural therapy
kidney disease CCF Congestive cardiac failure
xvi • ABBREVIATIONS

CD4 Cluster of differentiation 4 DIPJ Distal interphalangeal joints

CDC Centers for Disease Control and DIT Diiodotyrosine
Prevention DKA Diabetic ketoacidosis
CF Cystic fibrosis DLBL Diffuse large B-cell lymphoma
CFTR Cystic fibrosis transmembrane DLQI Dermatology Life Quality Index
conductance regulator DM1 Myotonic dystrophy type 1
CGA Comprehensive Geriatric DMARD Disease-modifying antirheumatic
Assessment drug
CGH Comparative genomic DMSA Dimercaptosuccinic acid
hybridisation DNA Deoxyribonucleic acid
CGRP Calcitonin gene-related peptide DOAC Direct oral anticoagulant
CIDP Chronic inflammatory DPP-4 Dipeptidyl peptidase 4
demyelinating polyneuropathy DRE Digital rectal examination
CIM Critical illness myopathy DRESS Drug reaction and eosinophilia
CJD Creutzfeldt–Jakob disease with systemic symptoms
CK Creatine kinase DVT Deep vein thrombosis
CKD Chronic kidney disease DXA Dual X-ray absorptiometry
CLL Chronic lymphocytic leukaemia E, V, M Eye, verbal, motor (in Glasgow
CML Chronic myeloid leukaemia Coma Scale)
CMV Cytomegalovirus EBUS-FNA Endobronchial ultrasound-guided
CN Cranial nerve fine needle aspiration
CNS Central nervous system EBV Epstein–Barr virus
CNV Copy number variant ECF Extracellular fluid
CO2 Carbon dioxide ECF Epirubicin, cisplatin and
COL4A5 Collagen type IV alpha 5 chain fluorouracil (cancer chemotherapy
COPD Chronic obstructive pulmonary combination)
disease ECG Electrocardiography
COX Cyclo-oxygenase ECMO Extracorporeal membrane
CPAP Continuous positive airway pressure oxygenation
CPE Carbapenemase-producing ECT Electroconvulsive therapy
Enterobacteriaceae ED Erectile dysfunction
CPPD Calcium pyrophosphate disease ED50 Median effective dose: the dose
CPR Cardiopulmonary resuscitation that produces a quantal effect (all
CRP C-reactive protein or nothing) in 50% of the
CRPS Complex regional pain syndrome population that takes it
CSF Cerebrospinal fluid EEG Electroencephalography
CT Computed tomography eGFR Estimated glomerular filtration rate
CT-PET CT positron emission tomography EGFR Epidermal growth factor receptor
CTKUB CT scan of kidneys, ureters and EIA Enzyme immunoassay
bladder ELISA Enzyme-linked immunosorbent
CTPA CT pulmonary angiogram assay
CTS Carpal tunnel syndrome EMG Electromyography
CVC Central venous catheter ENA Extractable nuclear antigens
CVD Cardiovascular disease ENT Ear, nose and throat
CVP Central venous pressure EPO Erythropoietin
CXR Chest X-ray ERCP Endoscopic retrograde
CYP Cytochrome P cholangiopancreatography
DBS Deep brain stimulation ESR Erythrocyte sedimentation rate
DDAVP Desmopressin ESRD End-stage renal disease
DGI Disseminated gonococcal ESWL Extracorporeal shockwave
infection lithotripsy
DILI Drug-induced liver injury ET Essential tremor
DILS Diffuse inflammatory EUS Endoscopic ultrasound
lymphocytosis syndrome FAP Familial adenomatous polyposis
 ABBREVIATIONS • xvii

FAST HUG Feeding, analgesia, sedation, HBeAg Hepatitis B e antigen

thromboprophylaxis, head of bed HBsAg Hepatitis B surface antigen
elevation, ulcer prophylaxis, glucose HBV Hepatitis B virus
control (mnemonic to help prevent HCC Hepatocellular carcinoma
intensive care complications) hCG Human chorionic gonadotrophin
FDG Fludeoxyglucose HCO3− Bicarbonate
FEV1 Forced expiratory volume in 1 HCV Hepatitis C virus
second HDL High-density lipoprotein
FFP Fresh frozen plasma HDV Hepatitis D virus
FHH Familial hypocalciuric HELLP Haemolysis, elevated liver
hypercalcaemia enzymes, low platelet count
FiO2 Fraction of inspired oxygen HER Human epidermal growth factor
FODMAP Fermentable oligosaccharides, receptor
disaccharides, monosaccharides HEV Hepatitis E virus
and polyols HG Hyperemesis gravidarum
FSGS Focal segmental HHS Hyperosmolar hyperglycaemic
glomerulosclerosis state
FSH Follicle-stimulating hormone HIT Heparin-induced
FVC Forced vital capacity thrombocytopenia
FXR Farnesoid X receptor HIV Human immunodeficiency virus
G-CSF Granulocyte colony-stimulating HIVAN HIV-associated nephropathy
factor HL Hodgkin lymphoma
G6PD Glucose-6-phosphate HLA Human leucocyte antigen
dehydrogenase HLH Haemophagocytic
GABA γ-Aminobutyric acid lymphohistiocytosis
GAD Glutamic acid decarboxylase HMS Hypermobility syndrome
GBD Global Burden of Disease HNF Hepatocyte nuclear factor
GBL Gamma butyrolactone HPOA Hypertrophic pulmonary
GBM Glomerular basement membrane osteoarthropathy
GBS Guillain–Barré syndrome HPV Human papilloma virus
GCA Giant cell arteritis HRCT High-resolution CT
GCS Glasgow Coma Scale HSV Herpes simplex virus
GFR Glomerular filtration rate HTLV Human T-cell lymphotropic virus
GGE Genetic generalised epilepsies HUS Haemolytic uraemic syndrome
GGT γ-Glutamyl transferase IA-2 Islet antigen 2
GH Growth hormone IABP Intra-aortic balloon pump
GHB Gamma hydroxybutyrate IARC International Agency for Research
GI Gastrointestinal on Cancer
GIP Gastric inhibitory polypeptide IBD Inflammatory bowel disease
GIST Gastrointestinal stromal cell IBS Irritable bowel syndrome
tumour ICD Implantable cardiac defibrillator
GLP-1 Glucagon-like peptide-1 ICD International Classification of
GLUTs Glucose transporters Diseases
GnRH Gonadotrophin-releasing hormone ICF Intracellular fluid
GORD Gastro-oesophageal reflux disease ICP Intracranial pressure
GPA Granulomatosis with polyangiitis ICS Inhaled corticosteroid
GVHD Graft-versus-host disease ICU Intensive care unit
H+ Hydrogen ion IDU Intravenous drug user
HACE High-altitude cerebral oedema Ig Immunoglobulin
HAP Hospital-acquired pneumonia IgA Immunoglobulin A
HAPE High-altitude pulmonary oedema IgE Immunoglobulin E
HAV Hepatitis A virus IGF Insulin-like growth factor
HbA1c Glycated haemoglobin IgG Immunoglobulin G
HBc Hepatitis B core antigen IgM Immunoglobulin M
xviii • ABBREVIATIONS

IGRA Interferon-gamma release assay MERS-CoV Middle East respiratory syndrome

IIH Idiopathic intracranial hypertension coronavirus
ILD Interstitial lung disease Mg2+ Magnesium
IM Intramuscular MGUS Monoclonal gammopathy of
INN International non-proprietary name uncertain significance
INR International normalised ratio MHC Major histocompatibility complex
IPF Idiopathic pulmonary fibrosis MI Myocardial infarction
IPSS International Prostate Symptom MIT Monoiodotyrosine
Score MM Multiple myeloma
IRIS Immune reconstitution MMF Mycophenolate mofetil
inflammatory syndrome MODY Maturity-onset diabetes of the
ITP Immune thrombocytopenia young
IV Intravenous MPA Microscopic polyangiitis
IVIg Intravenous immunoglobulins MRCP Magnetic resonance
JC virus John Cunningham virus cholangiopancreatography
JIA Juvenile idiopathic arthritis MRD Minimal residual disease
JVP Jugular venous pressure MRI Magnetic resonance imaging
K+ Potassium mRNA Messenger ribonucleic acid
KCO Carbon monoxide transfer MRSA Meticillin-resistant Staphylococcus
coefficient aureus
LABA Long-acting β2-agonist MS Multiple sclerosis
LADA Latent autoimmune diabetes of MSE Mental state examination
adulthood MSM Man who has sex with men
LAMA Long-acting muscarinic antagonist MSU Mid-stream urine
LDH Lactate dehydrogenase MTP Metatarsophalangeal
LDL Low-density lipoprotein MuSK Muscle-specific kinase
LEMS Lambert–Eaton myasthenic MVA Mosaic variegated aneuploidy
syndrome Na+ Sodium
LFTs Liver function tests NAD Nicotinamide adenine dinucleotide
LH Luteinising hormone NAFLD Non-alcoholic fatty liver disease
LMWH Low-molecular-weight heparin NASH Non-alcoholic steatohepatitis
LR Likelihood ratio NFFC Non-front-fanged colubrid (snake)
LSD Lysosomal storage disease NGS Next-generation sequencing
LUL Left upper lobe NHL Non-Hodgkin lymphoma
LUTS Lower urinary tract symptoms NICE National Institute for Health and
MALT Mucosa-associated lymphoid Care Excellence
tissue NIV Non-invasive ventilation
MAP Mean arterial pressure NMDA N-methyl-D-aspartate
MCI Minimal cognitive impairment NMO Neuromyelitis optica
MCP Metacarpophalangeal NNRTI Non-nucleoside reverse
MCPJ Metacarpophalangeal joint transcriptase inhibitor
MCTD Mixed connective tissue disease NNT Number needed to treat
MCV Mean corpuscular volume NR Normalised ratio
MDP Methylene diphosphonate NRTI Nucleoside reverse transcriptase
MDRD Modification of Diet in Renal inhibitor
Disease NSAID Non-steroidal anti-inflammatory
MDS Myelodysplastic syndromes drug
MEGX Monoethylglycinexylidide NSIP Non-specific interstitial pneumonia
MELAS Mitochondrial encephalopathy, O2 Oxygen
lactic acidosis and stroke-like OA Osteoarthritis
episodes OBMT Omeprazole, bismuth subcitrate,
MELD Model for End-Stage Liver metronidazole and tetracycline
Disease OCD Obsessive–compulsive disorder
MEN Multiple endocrine neoplasia OCP Oral contraceptive pill
MERS Middle East respiratory syndrome OGD Oesophago-gastroduodenoscopy
 ABBREVIATIONS • xix

OGTT Oral glucose tolerance test PTE Pulmonary thromboembolism

OPIDN Organophosphate-induced PTH Parathyroid hormone
delayed polyneuropathy PTLD Post-transplant lymphoproliferative
OSA Obstructive sleep apnoea disorder
PaCO2 Partial pressure of carbon dioxide PTSD Post-traumatic stress disorder
in arterial blood PUO Pyrexia of unknown origin
pANCA Perinuclear antineutrophil PVD Posterior vitreous detachment
cytoplasmic antibody RA Rheumatoid arthritis
PaO2 Partial pressure of oxygen in RAAS Renin–angiotensin–aldosterone
arterial blood system
PARP Poly-ADP ribose polymerase RAPD Relative afferent pupillary defect
PASI Psoriasis Area and Severity RBILD Respiratory bronchiolitis–interstitial
Index lung disease
PBC Primary biliary cirrhosis RFA Radiofrequency ablation
PBI Pressure bandage and RIC Reduced-intensity conditioning
immobilisation RNA Ribonucleic acid
PCI Percutaneous coronary ROSC Return of spontaneous
intervention circulation
PCNL Percutaneous nephrolithotomy ROSIER Rule Out Stroke In the Emergency
PCOS Polycystic ovary syndrome Room (clinical stroke tool)
PCP Pneumocystis pneumonia RPR Rapid plasma reagin
PCR Polymerase chain reaction rt-PA Recombinant tissue plasminogen
PD Parkinson’s disease activator
PDB Paget’s disease of bone RTA Renal tubular acidosis
PDT Photodynamic therapy RV Residual volume
PEA Pulseless electrical activity SAAG Serum–ascites albumin gradient
PEEP Positive end-expiratory pressure SABA Short-acting β2-agonist
PEFR Peak expiratory flow rate SaO2 Arterial oxygen saturation
PEP Post-exposure prophylaxis SARS Severe acute respiratory
PET Positron emission tomography syndrome
PHT Pulmonary hypertension SBP Spontaneous bacterial peritonitis
PIP Proximal interphalangeal SCC Squamous cell carcinoma
PIPJ Proximal interphalangeal joints SCLC Small cell lung cancer
PI Protease inhibitor SCRA Synthetic cannabinoid receptor
PKD Polycystic kidney disease agonist
75
PLE Polymorphic light eruption SeHCAT Se-homocholic acid taurine
PMF Progressive massive fibrosis SGLT2 Sodium and glucose
PMR Polymyalgia rheumatica co-transporter 2
PO2 Partial pressure of oxygen SHBG Sex hormone-binding globulin
POCT Point-of-care test SIADH Syndrome of inappropriate
POEM Peroral endoscopic myotomy antidiuretic hormone (vasopressin)
POMC Pro-opiomelanocortin secretion
PPARγ Peroxisome proliferator-activated SIJ Sacroiliac joint
receptor gamma SLE Systemic lupus erythematosus
PPCI Primary percutaneous coronary SO2 Saturation of haemoglobin with
intervention oxygen
PPI Proton pump inhibitor SOFA Sequential Organ Failure
PRV Polycythaemia rubra vera Assessment
PSA Prostate-specific antigen SpA Spondyloarthritis
PsA Psoriatic arthritis SPC Summary of product
PSC Primary sclerosing cholangitis characteristics
PSP Primary spontaneous SPECT Single-photon emission computed
pneumothorax tomography
PSS Primary Sjögren’s syndrome SpO2 Peripheral capillary oxygen
PT Prothrombin time saturation
Another random document with
no related content on Scribd:
placed nearly the whole of his hard-earned savings in
Mark's hands—and lost them.

Matthew had a hearty affection for his brother, but he

liked money too; and it was not in human nature—at least,
it was not in his nature to be indifferent to the loss of the
four or five hundred pounds which he had lent to Mark when
the certainty came home to him that they were lost. In his
first paroxysm of vexation, he vowed that, brother or no
brother, Mark Wilson should smart for his treachery; and,
though he soon cooled down in these thoughts of
vengeance, he declared that neither he nor his family
should hold any further intercourse with the man who had
stripped him of almost every ready-money pound he could
call his own.

This, however, was easier said than done. Matthew's

eldest son, Walter, was not only in love with, but had been
sometime affianced to, his (Walter's) pretty cousin, Mark's
daughter, and that with the mutual consent and liking of the
parents on either side. And Walter, at any rate, had no
thought of visiting the sins of the father upon the innocent
girl, and—himself. He even clung with the greater fondness
to poor Sarah, who could not be held accountable for her
father's misconduct and consequent misfortunes.

Matthew himself acknowledged this; but inwardly

determined, if possible, to sever the only remaining link
between his unlucky brother and himself; and probably
thinking, not unwisely, that such a connection would be a
drag to Walter in after-life, he insisted that his own altered
circumstances made it necessary that his eldest son should
leave home. He did this trusting to the probable chances
that absence would, in some way or other, effect the
separation which he had no power to compass by absolute
authority. But he had a fair reason also for this
determination. Walter, of all his sons, was the most fitted to
push his way in the world. And, added to this, an old
school-fellow and friend had made overtures to him to join
him in a distant part of the north country, where he himself
was established as a land surveyor.

These explanations given, we return to the two

disconsolate lovers.

They were again pacing the shady walk, sorrowful

enough; but Sarah's complaining mood had disappeared for
the time, and she was listening to the hopeful pleadings of
her lover. What lover is not hopeful? Can love be without
hope?

"It won't be long, darling. Two years will soon pass

away, and then I am to have a share in Ralph's business.
We shall be sure to get on, for Ralph is a capital fellow, and
so clever; and I—well, I can work, you know; and with you,
Sarah, to brighten up my prospects, I'll work like a slave,
and think nothing of it."

"Dear Walter!"

"The worst of it is, I shall be so far-away that it won't

be possible for us to see each other till the two years are
gone; but you won't forget me, love?"

"Forget you? Oh, Walter!"

"I know you won't: you are such a darling, you know, to
remember. And then, when the two years are past and gone
—"

"It is a long time to look forward to, Walter," sighed the

young lady. "I shall be quite an old woman by that time."
 "An old woman of twenty! What shall I be then? But we
won't make a trouble of that: only say that you'll try to
keep up a good heart. Courage, my pet, and all will turn out
well in the end. And as to this move, I don't know that it
isn't the best thing that could have happened. Farming isn't
much without plenty of money to carry it on; and if a fellow
like me hasn't got money, his knowing how to work on a
farm doesn't help him much. He is nothing better than a
day-labourer. So, Sarah dear, give me a kiss, and say 'tis all
right."

And so the lovers parted that evening.

The next morning, Walter was travelling far-away—

every mile widening the distance between him and all that
his heart held dear.

Walter Wilson was not a hero exactly; but he had some

good stuff in him, for all that. He was, at any rate, sturdy,
honest, persevering, and affectionate. All that is necessary
to say for him in this chapter, however, is that he reached
his destination in due course, joined his friend Ralph, and
entered with a good deal of energy on his new line of life.
Here, for the present, we leave him.

Poor Sarah, his cousin and affianced wife, had a more

trying ordeal to pass through. Her home was not a happy
one. Her father was now as often in liquor as sober, and, in
whichever state, he was dissatisfied and quarrelsome.

Her mother had never been very managing as a

farmer's wife, and what qualifications she once possessed,
had long since been abandoned. The cloud that hung over
her household was so dark and threatening that she could
see no light breaking through it, and she had become
hopeless. Worse than this, the habit which had ruined the
husband in health and circumstances was insensibly gaining
ground upon the wife. She drank secretly, and was for days
together incapable of conducting her family affairs. Then,
waking up to a sense of her degradation, she made feeble
and unsuccessful efforts to "set things to rights."

This was bad enough for the daughter, who had neither
strength of body nor mental capacity to cope with
surrounding difficulties; and who, now that Walter was
gone, had no one to encourage or comfort her. For she was
at feud with Walter's family.

Her uncle Matthew looked coldly upon her. Her aunt

treated her as if she were a puppet or a doll—so she said—
when they met, which was not very often, but it sometimes
could not be avoided; for Mrs. Matthew now and then
looked in to see how Mr. and Mrs. Mark were getting on,
and to report at home what she saw and heard. And these
reports served only to widen the breach between the two
brothers and their households.

As to her cousins, George, Alfred, and James, they

plainly made it to be understood that they considered their
brother Walter a fool for tying himself up to "a helpless bit
of goods" like Sarah, though she was his cousin and theirs.
And they were naturally enough bitter against their uncle
Mark for having made off with so much of their father's
cash.

All this was hard upon Sarah. Of course, if she had been
made of the stuff of which heroines are supposed to be
formed, she would have risen above all discouragements.
But she was not a heroine. She was merely a farmer's
daughter, poorly educated, but fond, and, we must add,
feeble also, with no particularly vivid apprehension of the
sterner duties of life, and with no very strong principle to
help her on in a course of self-denial and self-sacrifice,
should this be needed. She knew, however, or thought, that
she loved Walter, and she had full faith in his fidelity.

One of Sarah's greatest trials was in the unkindness of

her cousin Elizabeth, Walter's sister. With only a year
difference in their ages, the two girls had been very close
and intimate companions from childhood; and till within a
year or two of the date of our history, their friendship had
been unbroken. And it was Elizabeth who had been, first of
all, the secret prompter of the engagement between the
cousins, and then the private go-between of the two lovers
until that engagement was ratified by the higher powers.
Now, however, all old associations were severed; and
Elizabeth, as Sarah well knew, had employed all her skill,
though unsuccessfully as yet, to induce her brother Walter
to break off the match which she prophesied would be an
unhappy one.

Thus completely alienated from her former friends, and

more sinned against than sinning, with an unhappy home,
and more required of her in domestic duties than she had
power to accomplish, poor Sarah Wilson would have given
way to utter hopelessness but for the bright vision of Walter
and the happy home—in nubibus; where we must leave her,
while we take up the former thread of our drama.
 CHAPTER III.
THE PICNIC.

AS bright a day as could be desired opened upon

Richard Grigson's picnic. Determined that for one day at
least his recluse guest should be drawn out of his shell, the
hospitable master of the Manor House declared himself
unequal to the task of making preparation for his visitors
without John Tincroft's help. So the morning was occupied
in setting out tables, forms, and chairs on the lawn, in
daintily dressing up bowers, and, finally, in drawing up a
programme for the evening's entertainment.

"Are you much of a cricketer, Tincroft?" demanded the

squire.

"I detest the game," said John, heartily, remembering a

stunning blow he had received from a cricket-ball on
Bullingdon Green.

"That's capital. Then, while Tom and I are at it with the

young fellows, you will have to take care of the ladies."
 "Worse and worse!" exclaimed the guest, in sore
dismay. "Your brother knows I am not a ladies' man."

"The more's the pity," said the remorseless squire; "and

the more reason why you should begin to be."

"But, my dear friend—"

"There's nothing to be afraid of, Tincroft," put in Tom,

who rather enjoyed the perplexity of his college friend.
"There will be only a score or two of old women and a few
pretty girls. And if you don't succeed in amusing them, they
will amuse you, and themselves too, I daresay."

"If they can't do that, they will fare badly, I am afraid,"

said John, disconsolately, wishing himself for the time safe
back in his Oxford rooms.

"We shall have the parson here to help you out,"

continued Mr. Grigson.

"And to keep you out of mischief," added Tom, laughing.

With a heavy heart John Tincroft at length took refuge

in the library, anathematising all picnics in general, and this
one in particular; by the time the dinner-bell sounded, he
was deep in his Oriental studies.

It was an early dinner; but before it was well over, the

invited guests began to arrive, and were spreading
themselves over the lawn in detached groups, or were
wandering in the gardens, that day thrown open to them.
An hour later, they were clustering round the tables. An
hour later still, the wickets were pitched in an adjoining
meadow to which the host and his brother and the young
tenant-farmers had adjourned; while the fair sex, with a
sprinkling of the older men, were devising other means of
employing the next two or three hours of the evening.

Among these, in company with Mr. Rubric, the grey-

headed clergyman of the parish, John Tincroft walked about
uneasily. Under the protection of the reverend gentleman,
however, he managed not only to keep down his natural
shyness, and to conceal his awkwardness, but to make
mental notes of the, to him, strange society into which he
found himself thrown.

Especially his attention was drawn towards a

remarkably pretty young woman (so he thought her), who,
seated at one of the tables a little apart from the rest, was
pouring out tea—for the tea-things had not yet been
removed—for an elderly couple, the only other remaining
occupants of the half-dozen or more seats at that particular
table. The young person was rather smartly dressed; and
under her bonnet, which was redundant of pink satin bows,
shone out, as John believed, the brightest pair of blue eyes
it had ever been his fate to encounter. Perhaps it was the
previous exercise in the open air, or it might have been the
exertion of tea-making and tea-drinking, or it might even
have been the consciousness of having attracted the
attention of the gentleman from Oxford; but, from whatever
cause, a bewitching blush overspread her cheek, and
mantling there, took refuge under the fair, glossy hair which
hung low down so as half to conceal an alabaster neck in
delicious curls, for so John apostrophised both neck and
curls in his foolish thoughts.

It is not to be supposed that the Oxonian had more

than a hasty glance, for this first time, of the rustic beauty.
His natural shyness indeed would have cut still shorter even
this brief observation, if the clergyman by his side had not
halted at the table to make two or three commonplace
remarks to the elderly pair, who seemed not particularly
gracious in their replies.

Accordingly he, still accompanied by his friend from

Oxford, passed on to another group some distance off; at
another table. Here the pair were more pleasantly received,
and an invitation was given to them to take seats which, as
in the other instance, had been vacated. The invitation was
accepted.

"There's a cup of tea or two left in the bottom of the

pot," said an oldish lady who had officiated; "and there's
clean cups and saucers, and there's lots of cake."

"The boys were in such a hurry to get away to the

cricketing," added a farmerly man at her elbow, "that they
forgot what they came here for, I think."

While these and other compliments were passing, and

after being introduced to the hearty speakers, John Tincroft
noticed that this group consisted also of three individuals—
apparently, as in the former instance, father, mother, and
daughter. Singularly enough, also, there was considerable
resemblance between the two men at either table. They
were both elderly, grizzled, and weather-worn. Their
countenances were alike in form and feature, though
remarkably different in expression; and even the tones of
their voices were similar. The females, however, of this table
presented a striking contrast to those of the other: the
mother, if she were the mother, being stout and red-
checked, whereas the elderly woman in the other instance
was thin and pallid; while the daughter, if she were the
daughter, was coarse and hard-featured, with hands which
might, as John opined, have been accustomed to grasping
the stilts of a plough, or wielding a flail upon occasion.
 "And your eldest son Walter—you hear from him
sometimes, I suppose, Mr. Wilson? I hope he is getting on in
his new profession," said the clergyman, when one or two
other topics of conversation had been exhausted.

"Oh, bravely, sir. Ralph Burgess and Walter yoke

together uncommon. Their business is brisk, and Ralph says
as how Walter takes to it like anything."

"He has not been home to see you since he left, a year
ago or more, I think?"

"No, he hasn't," said the farmer; "he is a longish way

off, you see, sir."

"True."

"And a good thing too," said Mrs. Wilson, sharply.

"Indeed, my good friend; now I should have thought

you would have been glad for him to have been nearer you,
so that you might—"

"Better away," said the mother, interrupting her pastor.

"Dear me!" he ejaculated, quietly.

"You see, sir," interposed the husband, "we should be

glad enough to see Walter; but there's others, leastways
there's another, would be glad enough too. And that's what
we don't want."

"And don't mean, if we can help it," added the young

woman, who had not hitherto spoken; and the natural hue
of her cheeks glowed with a deeper, darker colour.
 "Ah! I understand," said the clergyman, rather
reprovingly, or so it seemed to John. "You mean that you
wish to break off his connection with his cousin," he looked
towards the other table as he spoke; "but is this quite right,
Mrs. Wilson? Do you think it is, friend Matthew?"

"Walter shan't marry Sarah if we can hinder him, right

or wrong," exclaimed the young woman, fiercely.

"Fie, fie, Miss Elizabeth!" the meek clergyman

interposed.

"I am not wanted here, I think," said the shy Oxford

man to himself, when he had heard enough to understand
that a family matter was in danger of being discussed.
Accordingly, he slipped away from the table, and wandered
without his guide to another part of the lawn.

By this time the tables on the lawn were for the most
part deserted, and the greater number of the tea-drinkers
had strolled into the cricketing meadow—the old farmers to
criticise the play of the juniors, and to compare the puny
strokes and new-fangled bowling of modern Toms, Dicks,
and Bills, with those of former cricketers in the good old
times when they themselves also knew how to handle a bat.
The young maidens went to watch and admire their lovers
and brothers as they increased the score of runs.

The lawn was not altogether left desolate, however, and

Tincroft noticed that the first trio of whom we have spoken
still lingered at the table where he and the rector had left
them. I do not know whether or not his curiosity was
quickened by the evident reference he had just heard to the
pretty girl at that board, or whether it arose from the
strange and unaccustomed sensation his accidental glance
had awakened in his breast; but certain it is that before he
had been alone many minutes, he was steering his course
towards the group. Not a straight course either; but by
repeated tacks, and as though he were unaware of his own
intention, he presently arrived within eyeshot of the pretty
flaxen curls, the alabaster neck, and the bright eyes of the
fair object of his admiration—yet not near enough to attract
special attention.

If he had not been shy and awkward, nothing of course

would have been easier than to have gone boldly up to the
table and, under cover of being the friend and guest of the
squire, making acquaintance with the elderly couple; and
thus have gazed his fill at the beauty by their side. This feat
was too daring to be attempted, however; and it answered
his purpose quite as well, probably, to gaze at the fair
Dulcinea at a safer distance.

The tea-drinking was over at that table as elsewhere;

and now John Tincroft was sorely troubled to see that the
pretty girl was crying. That is, he judged as much, for a
handkerchief was repeatedly used as though to wipe away
the tears which he was too far-off to discern. He was not
too far, however, to hear angry tones from the farmer,
either seconded or answered by shrill objurgations on the
part of his wife, and apparently directed towards the
weeping girl.

"I wish I knew what to do," muttered John to himself;

"but there, what have I to do with it? What's come over me,
I wonder?"

Leaving this question unanswered, John walked slowly

away; but either unable to resist the fascination which had
"come over" him, or moved by a chivalric desire to protect
the damsel, if need were, he presently retraced his steps,
venturing nearer this time, though partially concealed from
view under the foliage of an old chestnut tree, at the foot of
which was a rustic seat.

"I have a right to be here," quoth John, inwardly; "and

if people choose to talk loud enough in other people's
grounds to be overheard, it is no fault of mine."

If Mr. John had cared (which he did not) to hear the

dispute, he was baulked, for the conversation had by this
time subsided. He saw plainly enough, though, that the girl
was in some kind of distress, and he partly guessed the
reason when he observed that her father's face was flushed,
and that he was, with unsteady hand, pouring out into a
tea-cup some transparent fluid from a flask he had drawn
from his pocket. He had evidently had recourse to this
before, and was again raising the cup to his lips when a
voice from some distance caused him to hold his hand and
look round.

Tincroft looked too in the direction of the voice, and saw

his friend the clergyman, with Farmer Wilson and his wife
within a dozen yards of the table. It was Wilson who had
spoken. He spoke again when he came nearer.

"So you are at it again, Mark," said he, angrily, and

looking the other in the face. "If you must be getting
drunk," he added, snatching the cup out of the drinker's
hand, and dashing out its contents on to the greensward,
"you might at least have the decency to do it at home, and
not come here making a show of yourself, and disgracing
your kith and kin."

"And so I've been telling him, and so has Sarah," cried

Mrs. Mark; "but he wouldn't heed us—you know you
wouldn't, Mark," said she, deprecatingly.
 By this time the unhappy man, whom our readers will
before now have recognised, was on his feet, and giving
vent to ebullitions of rage against his wife, his daughter, his
brother, and all and sundry besides. And it was plain to
Tincroft that the poor miserable man had made such bad
use of his time and his gin-flask since tea as to be unsteady
alike on his legs and in his speech.

The quarrel might have heightened to a disturbance had

not the peace-making clergyman interfered, by replying to
the thickly-spoken demand of Mark to his brother—"What
business is it of yours what I do or don't do, Matthew? What
right have you to come prying about like a sneak, as you
are?"

"Gently, gently, friend," said the rector; "and you, Mr.

Matthew, don't answer your brother, for 'grievous words stir
up strife,' you know, and 'a brother offended is harder to be
won than a strong city.' It was I, Mr. Mark, who persuaded
your brother and sister to come and speak to you and Mrs.
Mark here. I told them that it would not look well if it were
known that you were all at this pleasant holiday party, and
should go away without having passed a word with each
other. I am sorry now that I interfered."

"Oh, never mind, sir, never mind," said the sober

brother; "Mark knows that I know that there's nothing new
in this. As good a fellow as ever lived, sir, till he took to
drinking; and now—there, the least said the soonest
mended."

And saying this, Matthew Wilson took his wife by the

arm and walked slowly away, leaving Mr. Rubric to make
what impression he might upon the unhappy brother.
 Meanwhile, as John Tincroft had seen from under the
chestnut tree, the pretty daughter of Mark had vanished
from the scene; and coincidently with this, all his interest in
it was over. He noticed only that his friend the clergyman
sat down by Mark's side, and seemed to be giving him a
quiet lecture, which was listened to, or rather received, in
stolid silence; and that afterwards, Mark and his wife
retreated through the gate of the Manor House grounds into
the high road, so that he saw them no more at that time.

Then, seeing that the rector was walking towards the

cricket-field, he followed, and joined company, arriving at
the ground just as his college friend Tom Grigson was
bowled out, after an innings of an hour, and having made
forty runs for his score.
 CHAPTER IV.
IN THE GROTTO.

JOHN TINCROFT soon got tired of the cricket ground,

and retraced his steps to the now deserted lawn. The sun
was near setting, but it was shining hotly nevertheless; and
the poor student, wearied with his day's exertions, and
somewhat perturbed in spirit as well, betook himself to a
cool grotto in a remote part of the grounds, which Richard
Grigson had had constructed for his own especial pleasure.

The grotto was not only cool, but secluded. It was built
of rough stones, after the manner of an ancient ruin, only,
unlike ruins in general, it was snugly roofed in, and was
weather-tight. It consisted of two chambers, the inner one
—which was accessible from the outer by a low archway—
being fitted up with some regard to comfort. Among the
accessories were a soft couch and a rough rustic table; also
a locker, in which were the materials, if required, for the
creature enjoyments of smoking and so forth.

Tincroft was not a smoker, nor did he care at that time

for treating himself hospitably, though a half-emptied bottle
of pale sherry end a tumbler might have tempted one who
was so inclined. As it was, he merely stretched himself
comfortably on his friend's couch, wondering what pleasure
could be found in entertaining a parcel of rustics, and
thinking that the life of a country gentleman, and a landlord
to boot, was not without its drawbacks, till his memory
went back to the pretty girl in pink bows and fair curls, and
his own disconsolate condition.

Finally, he dropped off into a sound slumber, "the world

forgetting, by the world forgot."

Was it a dream? It seemed like one; and yet, when the

sleeper lazily roused himself, and half raised himself on his
elbow, something like the following dialogue fell upon his
ear.

It should be noted that by this time the sun had

disappeared below the horizon, and the fast gathering
twilight was, within the walls of the grotto or hermitage,
intensified into a deeper gloom. The voices came through
the low archway, and the speakers, whomsoever they might
be, had evidently taken up their positions in the outer
chamber.

"And now we have come together, we don't part, miss,

till I have told you a bit of my mind." The voice of this
speaker was firm and strong and rough, though feminine.
To whom it belonged, the unintentional listener could only
guess. He had heard the same voice, however, in almost
equally harsh and loud tones, that same afternoon.

"It is very cruel of you, Elizabeth, to treat me so," was

said in reply, by another female speaker, and, as it seemed
to John, in piteous remonstrance. At any rate, the tones had
a musical softness and pathos which smote upon the
listener's heart.
 "It isn't cruel," said the first speaker; "it is only
straightforward and honest, and that is what I mean to be."

"Such friends as we used to be, Elizabeth," sobbed the

second interlocutor.

"And may be again, if you will only be sensible, and give

up Walter, as you ought to do."

"I won't, I won't, I won't!" cried the weaker one. "And

to think of your wanting me to do this, when you were the
first to—to—to make him fall in love with me."

"I didn't do anything of the sort," rejoined the other,

promptly; "and if I did," she added with a little
inconsistency and self-contradiction, "it was when we were
both children, and I did not know any better."

"And you are grown wiser since then, cousin—do you

mean to say that?" asked the harassed one, with a little
more spirit than before—for which John applauded her in his
heart. He understood it all now.

"Yes, I am grown wiser, miss," replied Elizabeth. "I

didn't know then how your father was robbing my father
and all of us."

"It isn't robbing. Father borrowed the money, and if he

could pay it back, he would; and if he can't, he can't."

"And why can't he? What's he always getting drunk for?

That isn't the way to get on, and to pay his debts, I reckon;
is it? And your mother, too—"

"I won't hear you talk like that—I won't; no, I won't!"
cried the unhappy girl, desperately. "Let me go, Elizabeth."
 There seemed then, to Tincroft, as though there were a
slight scuffle; but while he hesitated whether or not to
make his presence known by some audible token, it ceased,
and the conversation was resumed.

"There, there, I didn't mean to hurt you, Sarah," were

the first words spoken, and in response, as it appeared, to
the pantings and hysterical sobs of the weaker girl—"and I
don't believe I have. But I have not said what I had to say
to you, and I mean to say it."

"You may say what you like now, Elizabeth."

"I don't mean to say anything more about uncle Mark

and aunt," the other went on; "because I know as well as
you do, that you can't help that. And you and I might be as
good friends as ever, Sarah, if you would only be sensible,
as I said before, and see things as you ought. Now look,
dear—"

(Oh, thought John Tincroft, in his concealment—dear,

too! When women begin to call one another dear, it looks
ominous. So I have heard. Not that I know anything about
it. How should I?)

"Now, look, dear; you know you can't be Walter's wife

—"

"I don't know anything of the sort," said Sarah.

"Not for a long time, not for years and years, if ever."

"I'll wait, and so will he," replied the poor baited girl,
bravely; but with a perceptible tremulousness of voice,
nevertheless.
 "Ah, you think so now; but I know better. I won't say
anything about you, dear; but I know Walter better than
you do. He made up to you because you took his fancy. But
such fancies don't last long. Look at Mr. Elliston, of the
Mumbles; he was all hot for Miss Summerfield, as you
know. But he didn't have her, not he. He saw somebody
richer, and so he turned off his Laura—and glad enough she
is of it now. And it will be just the same with Walter and
you."

"You can go on, and say what you like," said Sarah,
panting for breath.

John Tincroft began to feel more uncomfortable in being

the involuntary hearer of all this family difference.

"Yes, I mean to, Sarah," continued the stronger-minded

cousin. "It will be just the same with Walter, I say. Why,
there's Miss Burgess, Mary Burgess he calls her, Ralph
Burgess's sister, who keeps house for her brother—you
should read what Walter writes about her."

"It isn't true—it isn't!" almost screamed the tortured

girl. "It's all stories you are telling, you good-for-nothing
thing, you!"

"And she has got money," the torturer went on, without
noticing the contradiction, or caring for the agony she might
possibly be inflicting; "and why shouldn't Walter have it?"

"Let him have it—let him!" cried poor Sarah.

"That's what I say, dear; let him have it. Why shouldn't
he? I declare if I was in your place, I should write and tell
him so at once. I think it would be very selfish in you to try
to keep him dangling after you when he has the chance of
bettering himself. Don't you see it in that light, dear?"